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FNP- First Review, AANP Lightening Round
Terms in this set (499)
Characteristics for Chronic Bronchitis
Chronic bronchitis is a type of COPD that is characterized by inflammation of the bronchi, chronic bronchitis characteristics include: dx after 35, obesity, copious amounts of purulent sputum, elevated Hct level
Treatment for Chronic Bronchitis
SABA (albuterol), inhaled anticholinergics (ipratropium)
What does Chronic Bronchitis cause?
Excess mucus due to the inflammation of bronchi
Exam findings with Chronic Bronchitis
Normal lungs: lower lobes vesicular breath sounds (soft/low); Upper lobes: bronchial breath sounds louder
What age group/race is more prone to Actinic Keratosis?
Older to elderly fair skinned adults
What does Actinic Keratosis look like?
merous dry, round, pink to red colored, slow growing lesions that do not heal
Where is Actinic Keratosis lesions normally found?
Lesions common on sun exposed areas (cheeks, nose, face, arms, back)
Describe Actinic Keratosis?
Precancerous precursor of squamous cell carcinoma
Risk factors for Actinic Keratosis
frequent sunburns as child
Diagnosing Actinic Keratosis and treatment:
diagnosed with biopsy, treat with cryotherapy (small number) or 5-FU (5% flurouracil) cream (large number); follow up with derm
What is seborrheic dermatitis?
soft, round, wart like fleshy growths on trunk (mostly back); can range in color from light tan to black and appear to be pasted on; asymptomtatic and benign
Fingernail hematoma treatment?
a. drill hole and drain blood (trephination)
Primary hypothyroidism defined and labs
abnormality in the thyroid gland itself; elevated TSH, low T4; low or normal T3
- elevated TSH, normal T3&T4
Most common cause of Hashimoto's (autoimmune)
Symptoms and treatment for Hypothyroidism
Variable symptoms (everything slows down); treatment: levothyroxine (Synthyroid) daily in AM on empty stomach, starting dose levothyroixine 25-50mcg, check TSH q 6-8 weeks to monitor exposure
Primary hyperthyroid labs
low TSH, high T4, normal or high T3
Subclinical hyperthyroid labs
low TSH, normal T4, normal T3
Most common cause of Grave's Disease
female, rapid wt. loss, increase HR, tremors, sweating, irritability, anxiety, hyperactivity, insomnia, diarrhea, amenorrhea, HTN, exophthalmos, heat intolerance, goiter
In pregnancy: propylthiouracil (PTU) is preferred; Methimazole (Tapazole); Radioactive iodine (causes hypothyroid for life-contraindicated in pregnancy).
Describe Thyroid Storm (thyrotoxicosis)
acute worsening of symptoms, may be caused by stress or infection, look for LOC, fever, abdominal pain, life threatening; immediate hospitalization needed
Risk factors for ectopic pregnancy
previous ectopic pregnancy, salpingitis, tubal surgery, current IUD use, previous cervicitis, hx of PID
Symptoms of ectopic pregnancy
abdominal pain (diffused, sudden, worsens with supine or with jarring), vaginal bleeding, amenorrhea, low grade fever, pain referred to right shoulder may indicate rupture
Initial HTN medications and African Americans
AA with or w/o DM -initial choices include thiazide or CCB
Initial HTN medications for non-AA
initial choices include thiazide diuretics, CCB, ACE or ARB
What is a thiazide diuretic?
-"ide"; excellent synergist, avoid in those with sulfa allergies, favorable in osteopenia/osteoporosis
Side effects of thiazide diuretics
hyperglycemia (caution in DM pts), hyperuricemia (gout attack), hypertriglyceridemia & hypercholsteremia (check lipids regularly), hypokalemia (potentiates digoxin toxcitiy and increases risk for arrhythmias), hyponatremia (hold diuretic, restrict fluid, replace K+)
Effects of thiazide diuretics
reduces edema by inhibiting reabsorption of Na, Cl, H20. Leads to a 2-8 pt drop in BP
What is an ACE inhibitor or ARB and when to use?
"pril" and ARB "sartan"; use in high renin states
When are ACE inhibitors the drug of choice and when are they contraindicated?
drug of choice for DM (protects kidneys) contraindicated in moderate to severe kidney disease; do not use ACE and ARB together
SE of ACE inhibitors and ARBs
ACE (dry/hacking cough), hyperkalemia, angioedema
What are beta blockers and when to use?
"lol"; good as an add-on medication, not uncomplicated HTN
How to discontinue use of beta blockers?
by weaning slowly, avoid abrupt discontinuation, to prevent rebound HTN
Contraindications for beta blockers:
Asthma, COPD, chronic bronchitis, emphysema (causes bronchoconstriction), bradycardia or 2nd or 3rd degree heart block; do not use Propranolol for HTN
Calcium Channel Blockers:
When are Calcium Channel Blockers appropriate?
as the 1st choice for ISA (isolated systolic HTN)
SE of Calcium Channel Blockers:
headaches (vasodilation), ankle edema (benign, vasodilation), heart block/bradycardia (depresses cardiac muscle & AV node), reflex tachycardia (nifedipine), contraindicated in 2nd & 3rd degree heart block, bradycardia, CHF
Heart Failure Treatment:
-digitalis increases strength of heart contraction
-diuretics-nutrient loss, glucose intolerance, increased serum uric acid
-diet: low sodium (2-3g), DASH, fluid restriction if needed; 1.2 g/kg (>1.37 g/kg if depleted) PRO BNP
ACEI or ARB 1st line treatment, plus BB & diuretic
Treatment for a diabetic patient with HTN
ACE or ARB 1st line of treatment; in AA start with CCB or thiazide
Treatment of HTN in patient with CKD
ACE or ARB 1st line treatment; can add CCB or thiazide
Treatment of HTN in patient with stroke Hx:
ACE or ARB 1st line treatment; can add CCB or thiazide 2nd line
Treatment of HTN in patient with Bilateral Renal Artery Stenosis:
ACE and ARB will worsen or cause acute renal failure
Risk factors for post menopausal osteoporosis:
older white or Asian women, small body frame, chronic steroid use, androgen deficiency, hypogondaism, ankylosing spondylitis, RA, low calcium intake, vitamin D deficiency, inadequate physical activity, ETOH/caffeine intake, smoking
Legg-Calves-Perthes disease (LCPD)
osteonecrosis of the capital femoral epiphysis due to interrupted vascular supply
Age/sex associated with Legg-Calves-Perthes Disease
males aged 3-12 (pre-pubescent)
Presentation and diagnostics for Legg-Calves-Perthes Disease
Pain in hip or referred to medial aspect of knee (may be present for 2-3 weeks before complaints), limp present.
Diagnostics: positive Trendelenburg's test (ask child to stand on affected side) causes pelvic tilt-affected side is lower
Cranial Nerves III, IV, VI assess _________________?
all assess EOM
III: oculomotor, eye movements, pupillary constriction, accommodation
IV: trochelear; movment of superior oblique muscle
VI: abducens; movement of lateral rectus muscle
Mneumonic for eye cranial nerves:
LR6SO4: Lateral rectus (VI, superior oblique IV)
Executive Functioning of a patent with Dementia
ability to manage a calendar
How to treat chlamydia in pregnancy
azithromycin 1g PO single dose or Amoxicillian 500mg TID X 7 days; test of cure 3 weeks after completion of treatment
Untreated gonorrhea in males may lead to
infertility and epididymitis
Untreated gonorrhea in women may lead to
PID, abscess, ectopiuc pregnancy ,infertility and can pass to baby during birth
Untreated gonorrhea in both men and women
can spread to blood and cause disseminated gonococcal infection (DGI) which is characterized by arthritis tenosynovitis, and/or dermatitis and may be life threatening, increases risk for HIV
is an infection of lacrimal sac/tear duct usually caused by blockage
Which age groups is dacrocystitis most common in?
infants and adults over 40
Symptoms of dacryocystitis
thick eye discharge, pain, redness/swelling/warmth of lower eyelid, watery eye/excess tears
Treatment for dacryocystitis
lacrimal sac massage (downward toward mouth), 2-3 times daily, systemic antibiotics 7-10 days
What is erysipelas?
cellulitis involving the upper dermis and superficial lymphatics
Cause and symptoms of erysipelas
caused by Group B Strep; symptoms: single large lesion, hot, indurated, read, clear demarcated margins, usually found on lower legs (shins), cheeks, fever ,chills
What is retinoblastoma and how is it diagnosed?
rare type of cancer, diagnosed by noting white pupil or pupil with white spots on it (leukocoria) - hallmark sign, may affect one or both eyes
What is a carotid bruit?
Narrowed blood vessel creates turbulence, causes blowing/swishing sound; caused by carotid stenosis (cholesterol plaque accumulation)
What is the murmur that radiates to the neck?
Which murmurs are abnormal?
What grade of murmur has a palable thrill?
MR ASS stands for:
Mitral Regurg, Aortic Stenosis - Systolic
MR Peyton Manning AS MVP stands for:
Mitral Regurg, Physiologic Murmur, Aortic Stenosis, Mitral Valve Prolapse
MS ARD stands for:
Mitral Stenosis, Aortic Regurg - Diastolic
On what side of the heart is the murmur heard the loudest on inspiration?
On what side of the heart is the murmur heard loudest on expiration?
Aortic murmur heard best on
right side of heart
Pulmonic murmur heard best on
left side of heart
Define mitral regurgitation
regurgitaed blood flow from LV to LA;• pansystolic/holosystolic; heard best at apex; radiates to left axilla; loud blowing/high-pitched; usually result of congenital condition, rheumatic heart disease, acute endocarditis, MVP, calcified annulus; symptoms include CHF, fatigue, dyspnea, bacterial endocarditis; LV/LA enlarged on XR; Afib common on EKG
Define Aortic Stenosis
midsystolic; best heart at 2nd ICS on right side; radiates to neck; harsh/noisy; patients should avoid physical overexertion (increased risk of sudden death); complications include angina, syncope, CHF; cardiomegaly occurs late; EKG usually normal; usually audible S4; usually congenital; rheumatic fever 2nd most common cause; monitor with echo; surgical valve replacement if worsens
Define Mitral Vavle Prolapse
systolic; heard best at apex; more common in women ages 14-20; symptoms include palpitations, chest pain, dyspnea, dizziness, numbness; first finding is midsystolic "click"; EKG usually normal. Rule out marfans syndrome in tall thin female with hypermobile joints. Arm span greater than height etc
Define Mitral Stenosis
Incomplete opening of the mitral valve during diastole, with left atrial distension and impaired filling of the left ventricle, low-pitched diastolic; rumbling; heard best at apex; "opening snap"; etiology is rheumatic fever; 4 stages (1 - long asymptomatic period followed by gradual reduction in exercise tolerance, 2 - pulmonary congestion, 3 - pulmonary HTN, 4 - severe low CO); symptoms include dyspnea, Afib, hemoptysis, RV hypertrophy; loud S1; may radiate toward axilla
Define aortic regurgitation
diastolic; high-pitched; blowing; best heard at 2d ICS on right side of sternum; symptoms include angina, CHF, dizziness, chest pain; etiology includes rheumatic heart disease, congenital deformity, aortic root abnormalities, syphilis; PMI displaced downward and left; water-hammer pulse
Patient forgot to start Thanksgiving dinner and husband states she has trouble remembering tasks and trouble with organization. This is indicative of:
Loss of executive function, Executive function includes the ability to manage a calendar, organizing, planning (getting things started), multitasking, processing/storing information
Patient with atopic dermatitis would be at risk for what other conditions?
asthma, allergic rhinitis, multiple allergies
What does atopic dermatitis look like?
atopic dermatitis (eczema) is marked by extremely pruritic rashes on hands, flexural folds (antecubital/popliteal space), and neck; rash is exacerbated by stress and environmental factors; rash appears as multiple small vesicles that rupture and leave painful, bright red, weepy lesions that become lichenified from chronic itching; fissures can form and can be infected with bacteria
Treatment for atopic dermatitis
topical steroids (1st line); systemic oral antihistamines; skin lubricants; hydrating baths
Patient with a history of PID has increased risk for?
Cervical Motion Tenderness (CMT)
elicited by moving the cervix often indicative of PID
Treatment of PID
Oral: Ceftriaxone 250mg IM then Doxy 100mg / Flagyl 500mg po bid x 14d
IV: Cefoxitin 2 q6h IV + Doxycycline 100mg IV q12h
No sex for 3 weeks, treat symptomatic PID even if GC and chlamydia tests are negative
When to follow up for patients with PID?
follow up with vaginal bimanual exam in 2-3 days to make sure symptoms are improving
Old lady with weakness on 2 HTN meds, 2 DM meds, vitamins
polypharmacy, hypotension, hypoglycemia
Wilms tumor (nephroblastoma)
cancerous kidney tumor of childhood, asymptomatic abdominal mass that extends from flank toward midline, nontender, smooth mass that rarely crosses midline of abdomen
Who has the highest incidence of Wilm's tumor?
higher incidence in black, female children, peak age 2-3, most common renal malignancy in children
Test and assessment for Wilm's tumor
when performing PE, palpate gently to avoid rupturing renal capsule, initial test is abdominal ultrasound
Follow-up: Baby with UTI?
renal and bladder ultrasound (RBUS) for all infants 2-24 months for first febrile UTI
Definitive diagnosis of Acute Bacterial Prostatitis Treatment
•UA and culture (treat empirically until results are back)
•Under age 35, treat like gonorrhea or chlamydia - Rocephin 250mg IM plus doxycycline 100mg PO BID x 10 days
• Over age 35, unlikely STD in nature, treat with Cipro PO BID or Levaquin PO daily x 4-6 weeks
In patient's with Acute Bacterial Prostatitis, vigorous palpation and massage of the prostate can lead to
• HTN stiffens vessels
• arteries indent and displace veins, vein appears to stop abruptly on either side of the artery
• considered "mild" retinopathy
Cotton wool spots on fundoscopic exam indicative of
• can be caused by HTN, DM, or other causes - microinfarct occurs
• considered "moderate" retinopathy
High triglycerides and pancreatitis: indication, treatment, lifestyle changes
• high risk of acute pancreatitis with triglycerides greater than 500
• normal level is less than 150
• if triglycerides are greater than 500, treat with niacin or fibrate or Niaspan to lower triglycerides; if less than 500, consider lifestyle modifications first
• once triglycerides are under control, switch target to lowering LDL
• recommend low fat diet, weight loss, and increased physical activity
Pancreatitis is diagnosed by...
• diagnosed with amylase and lipase lab draw
• amylase begins increasing 2-12 hours after onset of symptoms
• amylase is most widely used method of diagnosing pancreatitis
• lipase begins to increase 4-8 hours after onset of symptoms
• lipase more specific and sensitive to alcoholic pancreatitis
• common cause of knee pain in young athletes, especially if recent growth spurt
• anterior knee pain that increases over time
• osteochondritis of tibial tubercle
caused by overuse of knee - repetitive stress
• usually affects one knee, but can be bilateral
Osgood-Schlatter disease treatment
self limiting condition
stretching before and icing after
Rule this out before diagnosing with Osgood Schlatter
• rule out avulsion fracture if acute onset of pain post-trauma (lateral x-ray)
When to start patient on high intensity statin
• LDL >190; history of CHD or stroke
• High intensity statins include Atorvastatin (Lipitor) and Rosuvastatin (Crestor)
•Start screeing at 20 then every 5 years until 40 if no issues. At 40 every 2-3 years. IF dx then annually etc.
What classification are -statin meds?
• HMG CoA reductase inhibitors
Which age groups is dacrocystitis (tear duct infection) most common in?
infants and adults over 40
High intensity statins (meds) and lower LDL by
Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg
Lower LDL by 35-63%
Moderate Intensity statins lower LDL by:
lower LDL by 22-47%
Simvastatin, Pitavastatin, Pravastatin
Secondary Prevention with Atherosclerotic Cardiovascular Disease (ASCVD)
Patient with any form of ASCVD history of MI, CAD, Angina, stroke/TIA, PAD, coronary revascularization. If younger then 75 start on HIGH INTENSITY STATIN. Older than 75 (or not a candidate for high intensity) MODERATE INTENSITY statin.
Primary prevention no Atherosclerotic Cardiovascular Disease (ASCVD)
• NO ASCVD hx. LDL at 190 or > HIGH
• DM aged 40-75 with LDL 70-189 MODERATE
• Without DM or ASCVD age 40-75 with an estimated 10 yr ascvd risk of 7.5% or higher MOD to HIGH.
• Lack of any ASCVD but 10year is 5- <7.5% FIRST LINE is heart healthy lifestyle changes.
Pap smear recommendations
• Begin Pap at age 21 and repeat every 3 years until age 29
• Age 30 - Pap and HPV (primary screening); repeat every 5 years if negative
• Beginning age 65, may stop Pap if negative history x 10 years
• Discontinue in patients who have had hysterectomy with removal of cervix and no history of cervical cancer or high-grade lesion
• Satisfactory specimen only if both squamous epithelial cells and endocervical cells are present; if endocervical cells are missing, repeat Pap
MRSA treatment in patient with allergies
• If patient has sulfa allergy, treat MRSA with a tetracycline (doxycycline, minocycline)
• If no sulfa allergy, use Bactrim
Patient has Acute Otitis Media, gets hives with amoxicillian and n/v with erythromycin. What is the treatment?
• Trimethoprim sulfamethazole (Bactrim DS) PO BID
• Levofloxacin (Levaquin) or moxifloxacin (Avelox) - only if patient is 18 years or older - increases risk for tendonitis/Achilles tendon rupture
• If only Penicillin allergic, use azithromycin x 5 days or clarithromycin PO BID
• Knee pain and a "click" sound upon manipulation of the knee equals positive sign
• Suggests injury to medical meniscus, Meniscal tear
• Gold standard test for joint damage is MRI
Medial Pain in knee (Valgus/Varus)
• Valgus stress test - medial collateral ligament (MCL)
• Varus stress test - lateral collateral ligament (LCL) - Varus and Lateral both have R
• Positive finding is an increase in laxity of the damaged knee (ligament tear)
Sickle Cell Teaching
No cold water, no sports, avoid sick kids
• Diagnosis confirmed with hemoglobin electrophoresis (gold standard)
• suggest genetic counseling
• increased risk for death from infection with encapsulated bacteria due to hyposplenia
• recommend all required vaccinations
Bumps start on face or trunk and spread to rest of body:
• Classic presentation - pruritic vesicular lesions in different stages of development and healing
Adolescent with mild persistent asthma. What is the treatment?
• low dose ICS plus SABA (albuterol) PRN (preferred treatment)
• alternative treatment - cromolyn, Montelukast, nedocromil, or theophylline
Remember all asthma patients must have SABA as rescue med (safety issue
Infant had 2 episodes of RSV/Bronchiolitis. Now presents with fever, cough, wheezing. Differentials do not include:
Female with yellow/green vaginal discharge and itching?
• symptoms - frothy, yellow/green discharge; strawberry cervix; dysuria; vulvar irritation; pruritis; pH>5.0
• treatment - metronidazole (Flagyl) 2g x 1 dose or 500mg BID x 7 days; treat partner
Most common bug for otitis media?
• streptococcus pneumoniae
• treatment - amoxicillin is gold standard for all ages; if recent amoxicillin use or failed amoxicillin therapy, consider augmentin
Most common cause of death in women:
• heart disease
• heart disease is also the most common cause of death in men
• cancer is second most common
Lab test for Fifth Disease (erythema infectiosum)
• Parvovirus B19
• Diagnosis is usually made based on clinical presentation - "slapped cheek" - instead of lab test
• more common in children
• contagious through respiratory secretions
• symptoms include fever, headache, runny nose, rash
Person eating and notices painful lump in jaw that comes and goes:
• can also cause painful lump under the tongue, pain/swelling near ear or under jaw, dry mouth, gritty/strange tasting saliva, difficulty opening mouth, difficulty swallowing
• caused by salivary duct obstruction - worse when eating due to increased saliva production
ADHD: symptoms, diagnosis & treatment
• core symptoms - hyperactivity, impulsivity, inattention (behavior disorder)
• diagnostic criteria - symptoms present prior to age 12; symptoms last > 6 months; symptoms should be evident in 2 different settings (school and home - get feedback from caregiver/parent and teacher/coach)
• generally treated with Schedule II medications - high potential for abuse
Patient complains about upper arm tremor that seems to be hereditary. What is diagnosis & treatment?
• likely essential tremor
• treated with beta-blocker (Propranolol 60-320mg per day)
• alternative treatment is primidone (50-1000mg per day)
Highest suicide rates: age, race, sex, risk factors
• Age: 45-54 and >80
• Race: white
• Sex: male (females attempt more often, but males have a higher success rate)
• Risk factors: loss of spouse; history of attempted suicide; family history of suicide; mental illness; bipolar; depression; history of abuse; terminal or chronic illness; chronic pain; substance/alcohol abuse; significant loss (job, friend, divorce, death of someone close); plan to use gun
measures average glucose levels over the past 3 weeks; similar to A1C
• higher the level, poorer the degree of the glycemic control
• trend from high to normal may indicate treatment regimen is effective
• not used for screening
Treatment to prevent fracture in patient with low Vitamin D, high TSH, low Hct:
• Vitamin D 600-800 IU/day
• Calcium 1000-1200mg/day
Temporal arteritis defined and symptoms
a form of vasculitis that can cause headaches, visual impairment, jaw pain, and other symptoms
• symptoms - acute onset of unilateral headache located on the temple; jaw claudication (with chewing); fever; visual loss; pain in temple area
Screening test for Temporal Arteritis:
• gold standard for diagnosis - temporal artery biopsy done by ophthalmologist
• screening test - erythrocyte sedimentation rate (ESR); will be elevated
Treatment and complications for temporal arteritis:
• treatment - refer to ophthalmologist or ED; high-dose steroids are part of 1st line (prednisone 40-60/daily)
• complications - permanent blindness if not diagnosed early
Patient with ulcer in mouth: define and cause
• aphthous stomatitis (canker sores)
• single ulcers could also be caused by: trauma from biting, braces, tooth, hot food, toothbrush; food intolerance or allergy; stress; hormone changes; genes; medications; stopping smoking
What should be done before starting a -statin med? Labs ordered intially, monitoring, affect, increased risk for?
• baseline LFTs
• statins affect CYP450 system and increases risk for rhabdomyolysis and drug-induced hepatitis
• LFTs should be monitored periodically (more frequent for higher doses)
CDC recommendation on screening for Hep C:
• adults born between 1945 and 1965
• current or former IV drug users (even if use was only once and many years ago)
• persons who have HIV infection
• persons who have persistently abnormal ALT
• persons who received blood, blood components, or organ transplant before July 1992
• known exposure (needlestick, child born to HCV+ mom)
Zyprexa (olanzapine) recommendations: SE, monitoring
• high risk of weight gain, metabolic syndrome, and type 2 diabetes
• monitor weight every 3 months
• monitor TSH, lipids, BMI
Treatment for depression: 1st line mild to moderate
• first line for mild-to-moderate - SSRI (sertraline, escitalopram, fluoxetine, paroxetine, citalopram, fluvoxamine)
• TCAs are easiest to overdose on, which has caused a drastic decline in use
Treatment for BPH
• alpha-adrenergic antagonist - terazosin (Hytrin) or Tamsulosin (Flomax)
• 5-alpha-reductase-inhibitors - finasteride (Proscar); Proscar is teratogenic, category X. Reproductive-aged females should not handle with bare hands.
• BPH and HTN - start with alpha blocker (Hytrin) first
Treatment for depresssion: 1st line major
first line for major - SNRI (duloxetine, Effexor, Pristiq)
Treatment for depression: other treatment options
other treatment options - TCA (amitriptyline, Pamelor, doxepin, amoxapine) and atypicals (Wellbutrin, trintellix)
What classification of medications are not used to treat depression?
benzodiazepines are not used as treatment for depression
What classifications of medications are safest for treatment of depression?
What classifications of medications are the easiest to overdose on so are not used to treat depression?
• TCAs are easiest to overdose on, which has caused a drastic decline in use
Proscar causes prostate to shrink by _________. How to test its effectiveness?
• Proscar causes prostate to shrink 50%, so PSA should be doubled. To check effectiveness of treatment, obtain PSA and multiply by 2.
If patient has BPH and HTN, what is the treatment?
• start with alpha blocker (Hytrin) first
Positive Mantoux test indicates that...
the client has developed an immune response to TB it does not confirm active TB
• induration >=5mm
Induration of 5 mm or more indicative of
• Other cases when >=5mm is considered positive - recent contact with infectious TB, CXR with fibrotic changes consistent with TB, child who had contact with or TB symptoms (before age 5), immunocompromised patients (organ or bone marrow transplant, renal failure, patients on biologics)
Cases when induration is >10mm
• Cases when >=10mm is considered positive - recent immigrants (within last 5 years) from high-prevalence countries (Latin America, Asia, Africa, India, Pacific Islands), child/adolescent exposed to high-risk adult, IV drug user, health care worker, homeless, employees/residents from high-risk congregations (nursing home, jail)
Persons with no risk factors for TB, how large of an induration is positive?
if induration >=15mm
Optic disc in increased ICP looks like:
• optic disc swelling expected (papilledema)
• margins of disc will not be sharp/clear upon exam
• disc may be pale in color
testicular torsion define and ages typically affected
twisting of the spermatic cord causing decreased blood flow to the testis
• abrupt onset; extremely painful, swollen red scrotum; frequently accompanied by nausea and vomiting
• affected testicle is closer to the body/higher than unaffected
• missing cremasteric reflex
• usually occurs in adolescents (majority between ages 10 and 20)
When can personal damage occur with testicular torsion?
• permanent damage can occur if not corrected in less than 6 hours
• medical emergency - call 911, get to ER ASAP
Test and treatment for testicular torsion
• preferred test - Doppler ultrasound with color flow study
missing cremasteric reflex
• treatment - manual reduction or surgery with fixation sutures
Abnormal condition within the labyrinth of the inner ear that can lead to a progressive loss of hearing. The symptoms are dizziness or vertigo, hearing loss, and tinnitus (ringing in the ears).
• classic triad of symptoms - vertigo, tinnitus, hearing loss
• can resolve spontaneously or be chronic
Grade 1 murmurs are typically ____to hear
difficult; very soft, heard only under optimal conditions
Grade 2 murmur intensity:
quiet but readily audible with a stethoscope; mild to moderately loud murmur
Grade 3 murmur intensity:
easily heard with a stethoscope; loud murmur
Grade 4 murmur intensity:
louder murmur; first time thrill is present
Grade 5 murmur
Very loud, with thrill. May be heard when the stethoscope is partly off the chest; thrill obvious
Grade 6 murmur intensity:
heard with stethoscope off the chest wall; murmur so loud it can be heard even with stethoscope off chest; thrill easily palpable
Elderly with progressive hearing loss, loss of high pitch sounds, no lateralization:
• sensorineural hearing loss
• involves inner ear
• presbycusis, progressive, symmetric, high-frequency (human speech) lost first
Child with left otitis media with effusion:
• symptoms - aural fullness/pressure; ear being plugged; decreased hearing; pain is not common
• Weber test may show lateralization to affected ear
• tests CN 8
• tuning fork placed on midline on forehead
• normal finding - no lateralization; sound heard equally in both ears
• lateralization to affected/"bad" ear - abnormal finding - conductive hearing loss - AC (affected = conductive)
• lateralization to unaffected/"good" ear - abnormal finding - sensorineural loss - US (unaffected = sensorineural)
• tests CN 8
• place tuning fork fist on mastoid process, then at front of ear; time each area
• normal finding - air conduction is longer than bone conduction; heard in front of ear longer than on mastoid
• abnormal finding - bone conduction longer than air conduction - conductive hearing loss (cerumenosis, AOM)
Patient with fever of 102 for 2 days and blood coming from ear is indicative of:
• ruptured TM
Symptoms of peripheral artery disease
• symptoms - intermittent claudication (leg pain when walking; no pain at rest); lower extremities cool to touch; shiny, hyperpigmented, hairless skin on lower extremities; decreased/absent pedal pulse; increased capillary refill; bruits over partially blocked arteries
Highest risk factors for PAD
• higher risk for PAD with HTN, smoking, diabetes, hyperlipidemia
Treatment for PAD
Statins- help metabolize cholesterol; Crestor, Lipitor- muscle pain, leg pain, cramping, diarrhea
• treatment - smoking cessation, daily exercise, ankle and brachial BP before and after exercise.
• Pletal/Cilostazol or phosphodiesterase inhibitor vasodilator can be taken with ASA or Plavix.
What combinations of medications and food can increase serum concentration if taken together?
• Grapefruit juice, Cardizem, or Prilosec can increase serum concentration if taken together.
What is the last resort for PAD and the gold standard diagnosis?
• Last resort percutaneous angioplasty or surgery for severe cases.
• gold standard for diagnosis - angiography
Complications for PAD
• gangrene of foot or lower limb - requires amputation; increased risk of CAD or carotid plaques
• Ankle-Brachial Index ABI </= 0.9 is ABNORMAL and Dx PAD. 0.91-1.3 is Normal. To calculate take the SBP of each ankle and divide by the SBP of both arms.
inadequacy of the venous valves and impairment of venous return from the lower limbs (venous stasis), often with edema and sometimes with skin ulcers (particularly at the ankles)
• symptoms - edema, hyperpigmentation, chronic cellulitis, ulcerations, dilated leg veins, warm skin
Most common skin cancer
basal cell carcinoma
Degenerative Joint Disease (Osteoarthritis)
Progressive degeneration of articular cartilage; most common type of arthritis
Degenerative Joint Disease (Osteoarthritis) characterized by:
characterized by hard, non tender nodules, 2-3 mm or more; these ostephytes (bony overgrowths) of the distal interphalangeal joints are called Heberden nodes, and those of the proximal interphalangeal joints are called Bouchard nodes
Degenerative Joint Disease (Osteoarthritis) Treatment:
• exercise (swimming, walking, biking)
• lose weight
• stop smoking
• first line medication - acetaminophen (Tylenol)
• alternative therapies - glucosamine, SAM-e, acupuncture, Tai Chi
Exercises for osteoporosis
• weight-bearing exercises (walking, jogging, biking, aerobic dance)
• swimming and isometric exercises are not considered weight-bearing
Acne Rosacea presentation and treatment:
• light-skinned adult with Celtic background (Irish, Scottish, English); usually blonde/red hair and blue eyes
• papules and pustules around nose, mouth, and chin
• facial redness, especially in central part of face
• patient blushes easily
• may have red eyes, dry eyes, or chronic blepharitis
• treatment includes topical metronidazole gel
Patient is still having pain with a scaphoid fracture. What to do? Clinical presentation? Risk?
• repeat x-ray, splint wrist, refer to surgeon
• scaphoid fractures may not show on initial x-ray
• patient usually has history of falling forward on outstretched hand
• common complaint is deep, dull wrist pain that worsens with gripping or squeezing
• high risk of avascular necrosis and nonunion
• concerning even if very small amount
• refer to gyn for endometrial biopsy to rule out cancer
inflammation of the nerve typically between the 3rd and 4th metatarsals
Morton's Neuroma: Risks?
• increased risk with high-heeled shoes, tight shoes, obesity, dancers, runners
Morton's Neuroma: symptoms?
burning pain or numbness between 3rd and 4th toes; may have small palpable "pebble-like" nodule between 3rd and 4th toes
Morton's Neuroma: test and treatment?
• Mulder test/MTP squeeze test - grasp 1st and 5th metatarsal and squeeze forefoot - positive test is hearing click along with patient reporting pain during compression - pain relieved when compression stops
• treatment - avoid wearing tight, narrow shoes and high heels; use forefoot pad; wear well-padded shoes
• diagnosed by clinical presentation and history
• refer to podiatrist
Retinal detachment symptoms:
• symptoms - curtain-like shadow over visual field; gradual reduction in peripheral vision; flashes of light in one or both eyes; sudden appearance of many floaters
Retinal detachment causes and risk factors: `
• causes - sagging vitreous; injury; advanced diabetes
• risk factors - advanced age (over age 50); previous retinal detachment; family history of retinal detachment; extreme myopia; previous eye surgery (ex: cataract surgery); previous eye injury; previous eye disease/inflammation
Retinal detachment diagnosis & treatment:
• diagnosis - assess visual acuity first; dilated fundoscopic exam; slit-lamp biomicroscopy
• treatment - considered medical emergency; refer to ophthalmologist immediately
CD4 count less than 200 after antiviral treatment indicative of:
• diagnosis of AIDS should be made
• normal CD4 is 500-1500
• CD4 count increases as HIV virus is controlled with treatment
HTN medications that can cause GERD:
• Beta blockers (-lol)
• Calcium channel blockers (-pine)
Medications that can cause CHF:
• diabetes medications (glitazones)
• Calcium channel blockers/beta blockers
• Cancer medications
Treatment for ISH (isolated systolic hypertension) in elderly:
• calcium channel blocker (amlodipine, nifedipine, etc.)
• ISH = systolic >140 with diastolic <90
Contraindications for estrogen replacement:
• history of breast cancer
• coronary heart disease
• previous venous thromboembolic event or stroke/TIA
• active liver disease
• unexplained vaginal bleeding
• high-risk endometrial cancer
• active gallbladder disease
• thrombophilias (Factor V Leiden)
Bacterial endocarditis is:
an inflammation of the lining or valves of the heart caused by the presence of bacteria in the bloodstream
Bacterial endocarditis symptoms:
• symptoms - fever, chills, malaise associated with subungal hemorrhages (splinter hemorrhages on nailbed) and tender, violet-colored nodules on fingers/toes (Osler's nodes); palms and soles may have tender red spots on skin (Janeway lesions); may have heart murmur
Bacterial endocarditis treatment:
Antibiotic therapy until complete eradication achieved
• treatment - refer to cardiologist or ED for hospitalization and IV antibiotics; blood cultures x 3; CBC (WBCs will be elevated); ESR (elevated)
Bacterial Endocarditis complications:
valvular destruction; myocardial abscess; emboli
Prophylaxis for Bacterial Endocarditis:
• prophylaxis - not recommended for MVP, GU/GI incisions/invasive procedures (unless known infection present); recommended for patients with previous history of bacterial endocarditis, prosthetic valves, certain types of congenital heart disease, and cardiac transplant with valvulopathy when having dental procedures that traumatize oral mucosa, gingiva, or periapical area of teeth and invasive procedures on the respiratory tract; treat prophylactically with amoxicillin 1 hour before procedure (adults - 2g; children - 50mg/kg) or with clindamycin 600mg, clarithromycin (500mg) or cephalexin (2g) if penicillin allergic
Mammography screening guidelines:
• baseline mammogram at age 50; then every 2 years (biennially) until age 74
• age 75 and older - insufficient evidence for routine mammogram
• begin mammograms at age 40 for high risk patients; continue biennial schedule
Signs/symptoms of CHF:
• dyspnea/tachypnea, fatigue, dry cough, edema (feet and ankles), bibasilar crackles, S3 heart sound, resting tachycardia, diaphoresis
• early signs/symptoms involve heart and lungs
• later signs/symptoms involve periphery
• absence of menarche by age 15 (with or without development of secondary sexual characteristics)
Turner syndrome (45, XO)
rule out asymmetry of scapula or iliac crests
• Adams Forward Bend Test (Forward Bend Test) - have patient bend forward with both arms hanging free and knees straight; look for asymmetry of spine, scapula, thoracic and lumber curvature; inspect the shoulders and hips for asymmetry
• Monitor height
Lichen Planus define:
• small, flat topped, red to purple bumps that may have white scales/flakes; bumps may have wispy gray/white streaks called Wickham's Striae; itching mild to severe; commonly occurs on inner wrists, forearms, and ankles
• if it occurs on scalp, can cause hair loss
• can affect nails and cause them to become brittle or split with ridges
• in the mouth, it looks like lacy white patches on cheeks or tongue
Lichen Planus causes and treatment:
• causes - hepatitis C, medications, contact with certain chemicals
• treatment - usually goes away on its own; treatment focuses on symptom management (reducing itching)
Dosing thyroid medications in elderly:
• consider starting levothyroxine at 25mcg daily
• increase by 25mcg every 3-6 weeks until normal TSH
• recheck TSH every 6-8 weeks until normal TSH
• small decreases in thyroid replacement may be needed as patient ages
• upper limit of normal in TSH in 80-year-old is 7.5
advise patient to report palpitations, nervousness, tremors (indicate levothyroxine dose is too high)
Coumadin Therapeutic Range:
• therapeutic INR range - 2.0-3.0
Dosing for Coumadin based on INR range:
• <2 - increase coumadin dosage and repeat INR in 1 week
• >3 and <7 - decrease coumadin dosage and repeat INR in 1 week
• >7 and <10 - stop coumadin for 2 days and repeat INR in 1 week
• >10 - stop coumadin and examine patient
Elderly woman on digoxin; creatinine went from 0.8 to 1.2, what is going on?
• Normal creatinine in females - 0.6-1.1
• As renal function decreases, creatinine level increases
• As creatinine increases, eGFR decreases
• As creatinine increases, digoxin dosage will likely need to be decreased to prevent toxicity
Scenario: 18 week pregnancy with fundal height measuring 23 weeks. Why? Testing?
• possibilities include - dating error based on LMP; twins or multiples; fetus is healthy, but physically large; polyhydramnios
• order ultrasound
Scenario: Baby with yellow drainage from eye. Possible diagnosis?
• bacterial conjunctivitis
• gonococcal ophthalmia neonatorum
• chlamydial ophthalmia neonatorum (trachoma)
Classic presentation of Pyloric Stenosis and differential diagnosis?
• classic presentation - 4-6 week old (first born) male with projectile, nonbilious vomiting; olive-like mass better palpated immediately after vomiting; occurs in 3.5/1000 births
• differential diagnoses should include - GERD; milk protein intolerance; intestinal obstruction
Pyloric Stenosis diagnosis test and management:
• diagnosis made by ultrasound
• management - refer for surgical correction (laparoscopic pyloromyotomy)
Rubeloa: types and cause
• measles - caused by rubeola virus - measles, rubeola, and Koplik all have one L in them
• symptoms include fever, malaise, and the 3 Cs - conjunctivitis, coryza (runny nose, congestion), and cough
Rubeloa clinical presentation (skin).
• maculopapular "brick red" rash; starts on head and neck; spreads centrifugally to trunk and extremities
• Koplik spots - enanthem (rash on mucus membrane) associated with rubeola; 1-3mm white/blue/gray elevations on the buccal mucosa, hard, and soft palate; resemble grains of sand; precede rash
GERD with Barrett's Esophagus
• Barrett's esophagus is a long-term complication of GERD and is a premalignancy to esophageal cancer
• Barrett's esophagus is diagnosed by upper endoscopy with biopsy
• Any patient with at least a decade history of chronic heartburn should be referred to GI for endoscopy to rule out Barrett's esophagus
• treatment for Barrett's is PPI BID and H2 blocker qhs
• triptans are used as abortive treatment for migraines
• prophylactic treatment for migraines includes - avoid triggers, beta blockers (propranolol), TCAs (amitriptyline, nortriptyline), anticonvulsants (topiramate), gabapentin
• indirect Coombs' test is performed early in pregnancy to determine if there are antibodies to the Rh factor in the mother's blood
• If pregnant woman is found to be Rh negative, she will receive RhoGam at 28 weeks gestation and within 72 hours of delivery
• If pregnant woman is Rh negative and miscarries or terminates the pregnancy, she should still receive RhoGam
Allergic conjunctivitis in adolescents:
• caused by an acute type I hypersensitivity to allergen
• symptoms - itchy eyes, watery or stringy discharge, chemosis (swelling of the conjunctiva), eyelid edema, rhinitis, and an "allergic shiner"
• typically occurs bilaterally
• treatment is oral antihistamine
Otitis externa - "swimmer's ear" caused by:
• bacterial infection of the external ear canal
• more common during warm, humid weather (summer)
• common organisms - pseudomonas aeruginosa (gram -), staphylococcus aureus (gram +)
Otitis externa - "swimmer's ear" symptoms:
• symptoms - external ear pain, swelling, green purulent discharge usually following recent swimming
Otitis externa - "swimmer's ear" treatment:
• treatment - cortisporin otic drops QID x 7 days; keep water out of the ear during treatment
Scenario: Elderly lady with beefy red maceration under breast. Diagnosis & treatment.
• likely superficial candidiasis - superficial skin yeast infection promoted by increased warmth and humidity, friction, and decreased immunity; generally occurs in intertriginous areas (under breast, axillae, abdomen, groin, and web spaces between toes)
• treatment - nystatin powder/cream; OTC topical antifungal; keep skin dry and aerated
Patient with history of HTN and stroke now having memory loss; indicative of?
• vascular dementia
What is Molloscum contagiosum?
• small papules (5mm) that are dome-shaped with central umbilication and white "plug" (central dimple)
• contagious, spread by skin-to-skin contact
• If found on the genital area of young children, should raise suspicion of child sexual abuse
Scenario: Gravida 4 patient, hasn't given birth in 5 years and is producing milk; common cause of galactorrhea?
• too much prolactin is most common cause
• other causes include certain medications/drugs (sedatives, antipsychotics, antidepressants, antihypertensives, opioids, cocaine, marijuana, birth control pills, herbal supplements); pituitary tumor; hypothyroidism; CKD; excessive breast stimulation; spinal cord injury; nerve damage to chest wall
Scenario: Five-year-old child who was potty trained at age 3; has been soiling himself for 3 months. Indicative of what? Treatment?
• ikely encopresis - involuntary soiling of stool in a child 4 years or older
• as stool accumulates in rectum, enlargement can result in loss of sensation, loss of urge to defecate, internal anal sphincter relaxes, then stool leaks out
• constipation is underlying cause 80% of the time
• 4 times more common in males - in females, investigate sexual abuse
• management - laxative for initial cleansing, behavior changes (toileting habits), dietary changes
• goal is one soft stool per day
Signs of dehydration in infant:
*decreased heart rate (severe! HR is increased in moderate dehydration), prolonged cap refill, decreased turgor, sunken fontanel,
<1ml/kg/hour, decreased frequency of urination, no tears when crying, dry/sticky mucous membranes, lethargy, irritability
Contraindications for taking ACE inhibitor:
• moderate to severe kidney disease
• renal artery stenosis
• previous angioedema associated with ACE
Fundoscopic exam for HTN and DM:
• AV nicking (HTN) - arteries indent and displace veins, considered "mild retinopathy"
• Cotton wool spots (HTN, DM) - white spots on retinal surface caused by microinfarction, considered "moderate retinopathy"
• Flame hemorrhages, dot and blot hemorrhages (HTN, DM) - considered "moderate retinopathy"
Chief complaint of dizziness; assessment includes?
• Dix-Hallpike maneuver - positive would suggest benign paroxysmal positional vertigo
Seasonal affective disorder:
• depression that generally occurs in the winter months
• causative factors might include circadian rhythm, drop in serotonin level, change in melatonin level
• treatment - light therapy, antidepressants, psychotherapy/talk therapy
Psoriasis, silvery plaques that bleed when scratched:
• Auspitz sign - pinpoint areas of bleeding remain in the skin when a plaque is removed
Requirements for diagnosis of fibromyalgia:
• widespread pain
• tenderness when pressure is applied to at least 11 out of 18 body points
• experienced symptoms for at least 3 months
• all other possible causes ruled out
Scenario: Skateboard accident 2 days ago with concussion, still having headache.
• acute subdural hematoma
• diagnosed with CT
• depending on severity, watchful waiting may be appropriate treatment or, if more severe, may need draining or surgical intervention
Scenario: Patient describes "the worst headache of my life". Diagnosis? Clinical presentation? Treatment?
• subarachnoid hemorrhage
• usually accompanied by photophobia, nausea, vomiting, meningeal irritation (positive Brudzinski and Kernig signs), rapid decline in level of consciousness
• may experience "sentinel headache" a few days before the hemorrhage
• common causes - fall (elderly), MVA (younger)
• medical emergency
CBC which gives the Hgb count -- usually less than 6
MCV < 80 (microcytic anemia)
Iron test - can show iron overload
Hgb electrophoresis - Gold standard
Elevation of different types of hemoglobin in the body
Differentiates between normal and abnormal RBCs
Assess cognitive function in patient with signs/symptoms of memory loss:
• history is essential to diagnosis - focus on cognitive and functional concerns, psychiatric and behavioral changes
• MMSE - score < 24 strongly suggestive of dementia
• physical exam - look for neuro deficits, tremors, signs consistent with stroke, gait difficulty, cogwheel rigidity
• diagnostic labs will likely be normal in dementia patients
Sputum culture for TB:
• for diagnostic purposes, sputum for AFB smear and culture should be obtained
• at least 3 consecutive sputum specimens in 8 to 24 hour intervals - 1 of which is an early morning specimen
• sputum may be collected through cough (most common), sputum induction, bronchoscopy, gastric aspiration
What does liver produce in response to hypoglycemia?
• glucose - the pancreas releases glucagon which signals the liver to convert stored glycogen to glucose and release it into the bloodstream
Patient has 3+ proteinuria, what labs are needed?
• 24-hour urine for protein and creatinine clearance
• serum creatinine and albumin
• blood glucose
Adolescent UA results show WBC and squamous cells:
• likely contaminated sample
Risks for ovarian cancer:
• Family history of breast, ovarian, or colon cancer
• Age over 50
• Early menarche
• Late menopause
• First pregnancy after age 35 or never becoming pregnant
Ways to decrease risk for osteoporosis:
• vitamin D supplementation
• weight-bearing exercise
• stop smoking
• decrease alcohol/caffeine intake
Patient with HTN/CAD, present femoral pulses but absent pedal pulses: Possible diagnosis?
• peripheral arterial disease, arterial insufficiency
Characteristics of breast changes in elderly:
• breasts lose fat, tissue, and mammary glands
• breasts can become lumpy - from benign fibrocystic changes or from breast cancer
• breasts can become elongated, stretched, and flattened in appearance
Symptoms of serotonin syndrome:
• muscle twitching
• cluster of symptoms - abdominal obesity, HTN, hyperlipidemia or elevated triglycerides and low HDL, elevated fasting glucose >100
• patients are at higher risk for type 2 diabetes and CV disease
Allergic rhinitis (hay fever) defined:
• inflammatory changes of nasal mucosa due to allergy
• atopic family history
• may have seasonal or daily symptoms
Allergic rhinitis (hay fever) symptoms:
chronic nasal congestion with clear mucus discharge or post nasal drip, nasal itch, frequent sneezing, coughing worsens when supine, blue-tinged or pale boggy nasal turbinates
Allergic rhinitis treatment:
nasal steroid sprays, decongestants, antihistamine, avoid triggers
Hordoleum (stye) (signs and symptoms)
• painful acute bacterial infection of hair follicle on eyelid
• symptoms - itchy eyelid, acute onset of pustule on either upper or lower eyelid that becomes painful
Hordoleum (stye) (treatment):
To hasten drainage, hot compresses can be applied to the eye as soon as inflammation is evident
If surrounding soft tissue becomes infected, oral antibiotics may be needed
If persistent, these lesions need be surgically drained
• treatment - antibiotic drops or ointment, warm packs BID/TID until pustule drains
Corneal abrasion treatment
• treatment - rule out penetrating trauma, vision loss, soil/dirt; check vision; flush eye with normal saline; topical ophthalmic antibiotic (erythromycin or polytrim for 3-5 days); do not patch eye; follow up in 24 hours - refer if not improved; consider prescription for eye pain (only prescribe enough for 48 hours)
Corneal Abrasion symptoms:
• symptoms - acute onset of severe eye pain, patient keeps affected eye shut, patient reports feeling foreign body sensation, increased tearing of affected eye
Corneal Abrasion causes and diagnostics:
• could be caused by contact lens - very high risk of bacterial infection
• objective data - fluorescein dye strips with black lamp in dark room - appear linear
(+) Respiratory distress (tripoding, "sniffing" position)
usually occurs between ages 2-6
acute onset of high fever, chills, toxicity; child complains of severe sore throat; drooling; child won't eat or drink; may have muffled ("hot potato") voice; anxiety; may present with hyperextended neck with open-mouth breathing; may notice stridor, tachycardia, tachypnea
a) Lateral Neck XR ("thumb-print" sign)
b) Laryngoscopy (erythematous, edematous epiglottis)
b) IV ABX + IV steroids
c) Intubation if respiratory compromise
**ABX = cephalosporins
**May switch to oral ABX as they improve
Mild Acne Treatment:
• topical treatment only; tretinoin (Retin-A), benzoyl peroxide with erythromycin (Benzamycin) cream, clindamycin topical (Cleocin)
Moderate Acne Treatment:
• topical plus antibiotic; prescription topicals plus oral tetracycline/minocycline/doxycycline (tetracyclines can be given starting at about age 13, category D); certain oral contraceptives (Desogen, Yaz)
Severe Acne Treatment:
• isotretinoin (Accutane) - Accutane is category X and require special consent forms, approved pregnancy prevention program, 2 forms of reliable contraception, monthly pregnancy tests
Trigeminal neuralgia (tic douloureux): defined
• most composed by compression of nerve root by an artery or tumor, causing unilateral facial pain that is usually located close to the nasal border and cheeks
Trigeminal neuralgia (tic douloureux) classic presentation:
sudden onset of severe and sharp shooting pains on one side of the face triggered by chewing, eating cold foods, and cold air; severe pain lasts a few seconds
Trigeminal neuralgia (tic douloureux) treatment:
high doses of anticonvulsants (carbamazepine or phenytoin); MRI/CT if patient is young, bilateral involvement, or numbness
COPD treatment by stages: 1-4
• 1 - short acting anticholinergic PRN or SABA PRN
• 2 - long acting anticholinergic or LABA plus rescue med
• 3 - ICS + LABA or LA anticholinergic plus rescue med
• 4 - ICS + LABA and/or LA anticholinergic plus rescue med
Asthma meds: intermittent
Asthma meds: persistent
• persistent symptoms (stepwise approach) - low dose ICS; then low dose ICS plus LABA or medium dose ICS; then, medium dose ICS plus LABA
All asthma patients should have?
Rheumatoid arthritis (RA) defined:
systemic autoimmune disorder; more common in women; manifested through multiple joint inflammation and damage; patients at higher risk for other autoimmune disorders; symptoms include gradual onset of symptoms, daily fatigue, low-grade fever, generalized body aches, myalgia, morning stiffness lasts longer, generalized aching joints that usually involves fingers/hands/wrist, painful/warm/swollen joints, swollen fingers with warm tender joints (PIP and DIP); joint involvement is symmetrical; elevated ESR; treated with NSAIDs, steroids, DMARD, surgery, biologics, anti-TNF; complications include uveitis, scleritis, vasculitis, pericarditis, increased risk of certain malignancies
Rheumatoid arthritis (RA): symptoms
symptoms include gradual onset of symptoms, daily fatigue, low-grade fever, generalized body aches, myalgia, morning stiffness lasts longer, generalized aching joints that usually involves fingers/hands/wrist, painful/warm/swollen joints, swollen fingers with warm tender joints (PIP and DIP); joint involvement is symmetrical;
Rheumatoid Arthritis labs:
Rheumatoid Arthritis Treatment
-goal of tx: reduce inflammation and pain, promote joint function, and prevent joint destruction and deformity
-Pharmacological management includes NSAIDs to reduce inflammation and pain
-Corticosteroid meds may be desirable during severe flare-ups or when the patient's condition is not responding to NSAIDs
-Disease-modifying antirheumatic meds are slow-acting and take weeks or months to become effective, however, they have the ability to slow the progression of joint destruction and deformity
-PT interventions include passive and active ROM, heating and cooling agents, splinting, patient education, energy conservation, body mechanics, and joint protection techniques
Osteoarthritis (OA) (Degenerative Joint Disease)
inflammation of the bone and joint; affects large weight-bearing joints (hips, knees) and hands; risk factors include older age, over use, positive family history
Osteoarthritis (OA) (Degenerative Joint Disease) symptoms:
symptoms include gradual onset, early morning joint stiffness with inactivity, shorter duration of joint stiffness than RA, pain aggravated by overuse, joint may be swollen and tender during exacerbation, may be one-sided, no systemic symptoms, heberden's nodes
Osteoarthritis (OA) (Degenerative Joint Disease) Treatment:
• treatment includes acetaminophen (first line), NSAIDs (if acetaminophen fails), capsaicin cream, weight loss, smoking cessation, exercise; rule our osteoporosis
STD with strawberry cervix:
Treatment of chlamydia:
• Azithromycin 1g PO in a single dose OR
• Doxcycline 100mg BID x 7 days - use Amoxicillin 500mg TID x 7 days in pregnant women
Calcium supplement in pregnancy:
• 600mg BID (1200mg per day)
Trichomoniasis symptoms in females:
• female symptoms - frothy, yellow/green discharge; vulvar irritation; dysuria; cervical petechiae (strawberry cervix)
Trichomoniasis symptoms in males:
dysuria; epididymitis; prostatitis
wet prep, showing motile trichomonads
can confirm with culture if needed
(flagellated, motile cells); vaginal pH>4.6
flagyl 2g single dose (okay in all trimesters of pregnancy) OR tinidazole 2g single dose OR flagyl 500mg BID x 7 days (HIV+ pts); abstinence until treatment complete; abstain from alcohol during treatment
Medication for BPH with HTN:
start with alpha blocker (Hytrin) - works by relaxing smooth muscles on prostate gland and bladder neck
Treatment for generalized anxiety disorder:
1st line > SSRI and SNRI; benzo > short-term, nondepressed, no hx of substance abuse, respond poorly to antidepressants
• SSRI, SNRI, buspirone
• may need benzodiazepine for limited time
Scenario: Patient with triglycerides 1250 already on Niacin, what should be added?
• very low-fat diet, weight loss, increase physical activity
• add a fibrate medication (Lopid, Tricor)
• can do insulin infusion to quickly lower triglyceride level
• infestation of the skin by sarcoptes scabiei mite; burrows under skin; transmitted by close contact
• Treatment - permethrin 5% (apply to entire body - wash off in 8 hours); treat everyone in the household; wash all clothes/bedding in hot water and dry
Scabies clinical presentation
• symptoms - pruritic rashes located in the interdigital webs of the hands, axillae, breasts, buttock folds, waist, scrotum, penis; severe itching that is worse at night and interferes with sleep; serpinginous (snakelike) rash and/or linear burrows; lesions can be popular, vesicular, or crusted
Herpes Keratitis defined:
acute onset of severe eye pain, photophobia, and blurred vision in one eye
infection permanently damages corneal epithelium (may result in blindness)
Herpes Keratitis diagnosis & treatment:
diagnosed by using fluorescein dye - will appear like fernlike lines on the corneal surface
refer to ED or ophthalmologist STAT; avoid steroid ophthalmic drops
Treatment for Kawasaki Disease:
• treatment - high-dose aspirin and gamma globulin
• close follow up with pediatric cardiologist for several years
Symptoms of Kawasaki Disease:
onset of high fever (up to 104) and enlarged lymph nodes on neck; bright red rash (more obvious in groin area); conjunctivitis; dry, cracked lips; "strawberry tongue," swollen hands and feet; after fever subsides, skin peels off hands and feet
Occurrence and resolution of Kawasaki Disease:
• occurs most commonly in children under age 5; resolves in 4-8 weeks but may have serious sequelae such as aortic dissection, aneurysms of coronary arteries, and blood clots
Slipped Capital Femoral Epiphysis (SCFE) defined:
This condition usually occurs in 10-16 year olds during rapid growth, when even minor trauma can precipitate its development. The epiphysis appears shorter and the epiphyseal plate wider, with smaller margins.
Slipped Capital Femoral Epiphysis (SCFE) diagnosis:
• diagnosis often missed because only 50% have hip pain and 25% have knee pain
• on x-ray, the femoral head is seen displaced, posteriorly and inferiorly in relation to the femoral neck and within the confines of the acetabulum
Slipped Capital Femoral Epiphysis (SCFE) treatment:
• treatment - surgical repair with internal fixator
• goal is to prevent complications like avascular necrosis
Side effects of thiazide diuretics:
• hyperglycemia (careful in diabetics)
• elevates triglycerides and LDL (careful in preexisting hypertriglyceridemia)
• elevates uric acid (can precipitate a gout attack)
• hypokalemia (muscle weakness, arrhythmia)
Contraindications for beta blockers:
• asthma, COPD, chronic bronchitis, emphysema, second and third-degree heart block (okay with 1st degree), sinus bradycardia; do not use Propranolol for HTN
Symptoms of Polymyalgia rheumatica:
• symptoms - bilateral morning stiffness and aching (more than 30 minutes) in shoulders, neck, hips, and torso; difficulty putting on clothes/bra
• mostly affects females age 50 and above
Treatment for Polymyalgia rheumatica:
• treatment - oral steroids (prednisone)
Patient education related to Polymyalgia rheumatica:
• PMR patients are at very high risk for developing temporal arteritis (educate on recognizing symptoms)
Scenario: Frail elderly - anemia.
• older patients tend to have lower H&H then younger patients
• up to 20% can have "idiopathic anemia of aging"
• never presume anemia in elderly is due to aging
Testing for pinworms:
• scotch tape test
• apply scotch tape on the anal area in the morning before showering, then transfer the tape to a slide and take to the health care provider who will check the tape for eggs
• the worms come out at night to lay eggs in the anal area - that's why the morning is the best time to test
• scotch tape test will need to be done several days in a row as females do not lay eggs everyday
Define & clinical presentation of Neuroblastoma:
painful abdominal mass that is fixed, firm, irregular, and frequently crosses the midline; the most common site is the adrenal medulla; about half of patients present with metastatic disease
Symptoms of Neuroblastoma:
may be accompanied by weight loss, fever, Horner's syndrome (miosis, ptosis, anhidrosis), periorbital ecchymoses ("racoon eyes"), bone pain, hypertension; most are diagnosed in children between ages 1 and 4
Treatment for Neuroblastoma:
• elevated urinary catecholamines and anemia; initial imaging is ultrasound; refer to nephrologist
Positive signs of pregnancy
• palpation of fetus by health care provider
• ultrasound and visualization of fetus
• fetal heart tones (FHT) auscultated by health care provider (10-12 weeks by Doppler, 20 weeks by stethoscope)
• ciprofloxacin 500mg BID x 60 days (alternate is doxycycline)
Sinus tachycardia causes:
• blood loss
What is pulsus paradoxus?
When the BP > 10 mmHg on expiration than on inspiration
• apical pulse can be heard but radial pulse is not palpable
• measured by using BP cuff and stethoscope
Causes of pulsus paradoxus
• causes - asthma, emphysema (increased positive pressure), tamponade, pericarditis, cardiac effusion
Hyperparathyroidism diagnosis: Labs?
• elevated levels of serum calcium and parathyroid hormone (PTH)
Benzodiazepine use for 6 years medication change is needed?
• Do not discontinue abruptly - increased risk of seizures
Scenario: Child in with fever and otitis media; has appointment in 2 weeks for 12 month shots; mom wants to cancel that appointment and get shots today; what do you tell mom?
• Vaccines scheduled for 12 month visit generally include MMR and varicella - these cannot be given before 12 months of age
Wolff-Parkinson-White Syndrome defined:
Most common type of ventriuclar pre-excitation sydnrome. Abnormal fast accessory conduction pathway from atria to venricle bypasses the rate-slowing AV node causing a delta wave and widening QRS with shortened PR interval. Could lead to a reentrant circuit and suprvaventicular tachy.
Most common in children
Paroxysmal Supraventricular Tachycardia (PSVT)
rapid palpitations due to stimulation of atria/AV node.
Ekg shows tachy with PEAKED QRS complex with P waves.
Treat with ADENOSINE to very rapidly slow conduction through the AV node.
Side effects of adenosine:
Wolff-Parkinson-White Syndrome treatment:
"Procainamide, quinidine. AVOID digoxin and verapamil"
Treatment If shows WPW or symptomatic refer to Cardiologist for possible cardioversion and call 911
Vagal maneuvers, if carotid massage needed refer to cardiologist.
Carotid massage is contraindicated with a history of TIA or Stroke in past 3 months or has carotid
Wolff-Parkinson-White Syndrome causes:
Dig toxicity, alcohol, hyperthyroidism, caffeine intake, illegal drugs, etc.
150-200 bpm with palpitations, SOB, anxiety etc
Most common arrhythmia. Treatment?
Treatment: Rate control by CCB, BBs, digoxin
This combination of medications increases risk for Rhabdo?
Simvastatin and Amio
When to start anticoagulants such as warfarin for Afib based on age? What is INR goal?
Start older than 70years on 2.5mg not 5mg which is dose for ppl under 70.
INR goal 2-3.
INR goal for synthetic/prosthetic vales:
Goal INR: 2.5-3.5
Do not give Vit K dose unless at ____________?
5.0 or above, hold a dose.
The most common and serious type of MI & presentation on EKG.
Anterior Wall MI or anterior STEMI
EKG includes ST segment elevations in V2 and V4, and Q waves. Wide QRS complex resembles a tombstone.
Numerous dry, round, pink to red-colored, slow-growing lesion that doesn't not heal and found mostly in older to elderly fair skinned adults?
Actinic Keratosis, sun exposed area such as cheeks, nose, face, arms and back.
Diagnosed by biopsy
tx includes cryotherapy or 5- FU(5% fluorouracil) cream. F/u with dermatology.
Soft, round, wart-like fleshy growth on trunk or back ranging in color from light tan to black and appears as pasted?
Seborrheic Keratosis. Benign and asymptomatic.
Possible side effects of Nifedipin (Procardia) includes?
Edema of the ankles, HA, dizziness, flushing, weakness.
Name some drugs that cause confusion in elderly
Tagamet, dig, benedryl.
Elderly female complaining of room spinning or moving which is worsened by sudden head movement along with some nausea. What are you thinking and how do you treat this pt?
Antivert (Meclizine)12.5 mg to 50 mg tid to qid for vertigo. Diuretics and valium.
TZD also know as thiazolidinediones contraindicated in which condition?
CHF as it causes fluid retention.
Infection of lacrimal sac/tear duct know as?
Dacrocystitis. Symptoms includes thick eye discharge, pain, redness/swelling/warmth of lower eyelid.
Tx includes lacrimal sac massage downward toward mouth 2-3 times daily and systemic antibiotics if needed.
Skin infection involving upper dermis and superficial lympahtics is know as?
Erysipeals caused by strep A and has clear demarcated boarder, tx includes PCN such as dicloxacillin qid x 10 days, Cephalexin, clindamycin for PCN allergic do Azithromycin
Skin infection involving deep dermis is know as?
Cellulitis, gram + bacteria (Staphylococcus. aureus). MRSA strain is a virulent strain that causes aggressive skin infections. Nonpurulent form of cellulitis caused due to streptococci but it could be also staphy.
Poorly demarcated with advancing margins, lesion feels warm to touch, may have abscessed or it may be fluctuant (pointing) or draining pus.
MRSA tx: Bactrim, Clinda, or Doxy. Non MRSA infection: Keflex
Tx for cutaneous anthrax?
Doxycycline bid, cipro bid or levofloxacin bid 7-10 days. If bioterrorism suspected treat for 60 days.
What education would you provide to patient who is taking flagyl?
Avoid alcohol drinks or medicine as it can cuase disulfiram (antabuse) effects such as sever n/v, flushing, tachycardia and sob.
Triple therapy for H pylori positive?
Clarithromycin (biaxin) bid, Amoxicillin bid or flgyl and Omeprazole (Prilosec) daily.
What is the new psoriatic plaques form over areas of skin trauma called?
Patient complains of recurrent episodes of painful, large, dark-red nodules, abscesses, and pustules. Ruptured lesions drain purulent green colored discharge. Pain resolves when the abscess drains and heals. Lesions take from 10-30 days to heal. Hx of recurrent episodes on the same areas in the axilla?
Hidradenitis suppurativa, common in women and risk factors includes smoking and obesity.
Tx chlorhexidin (Hibiclens) 4% solutions or antibiotic soap, topical antibiotics such as clindamycin 1% solution with/without benzoyl peroxide, warm compress, sitz baths, topical and/or oral pain medication for pain. An oral antibiotic includes tetracycline 500 mg bid or doxycycline or minocycline bid 7-10 days for mild case.
Refer to surgery, hormonal therapy, laser therapy and cryotherapy
Honey colored crusts seen in patient with?
Tx: Mupirocin (Bactroban) 2% ointment. For severe cases Keflex qid, dicloxacillin qid. Use macrolides such as azith or clinda x 10 days.
Contagious so keep kids home for 48-72 hours after initial tx
Skin lesions caused by the bite of tick know as?
Erythema migrans caused by B. Burgdorferi.
Lab includes: EIA or ELISA (enzyme immunoassay, if negative no further testing is recommended.
If first test is positive the second test is the indirect immunofluorescence assay (IFA or "wester blot" test). If both EIA and IFA tests positive person has lyme infection.
Tx: Doxycycline bid x 10 days or Amoxicillin 500 mg tid or ceftin (cefuroxime) 500 mg bid x 14 days
Herpetic whitlow is viral skin infection caused by?
Herpes simplex (type 1 and 2) virus infection and results from direct contact with either a cold sore or genital herpes lesion.
Patient complains of acute onset of extremely painful red bumps and small blisters on the sides of the finger or the cuticle area or on the terminal phalanx of one or more fingers. Ask patient about coexisting symptoms of oral herpes or genital herpes.
Tx: NSAIDs for pain, severe infection use Acyclovir.
Patient reports of acute onset of painful and red swollen area around the nail on a finger that becomes abscessed. The most common location are index finger and thumb. Reports of hx of picking a hangnail, biting off hangnail, or of trimming the cuticle?
Paronychia (acute local bacterial infection).
Tx: soak affected finger or toe in warm water for 20 mintues, topical antibiotics such as mupirocin. If abscess do I&D.
Herald patch is seen in which condition?
Pityriasis Rosea. Also has Christmas tree pattern. It will take 4-6 weeks to resolve. If high risk of STD check RPR (rapid plasma reagent) to r/o secondary syphilis.
Patient c/o pruritic rashes located in the interdigital webs of the hand, axillae, breasts, buttocks folds, waist, scrotum, and penis. Severe itching that is worse at night and other family members may have the same symptoms known as?
Scabies tx includes: Permethrin 5% cream from the neck to the feet and wash off after 8-14 hours. Repeat treatment in 7 days.
Pruritus usually improves in 48 hours but can last up to 2-4weeks. Do not retreat and do we mount to check for live mites.
Treat itch with anithistamines and topical steroids.
Mild acne tx?
Topical only, open comedones (blackheads), closed comedones with or without small papules are considered mild acne.
Retin-A, Benzoyl peroxide gel with erythromycin or with clindamycin. (OTC salicylic acid then use Retin-A).
Moderate acne tx?
Presence of papule and pustules with comedones.
Tx includes topical such as Retin-A, benzoyl peroxide combined with erythromycin.
Add oral antibiotics such as tetracycline or mino, doxy or erythromycin or clinda
Patient with light skinned color with background of Scottish or English complaints of chronic and small acne like papulses and pustules around the nose, mouth and chin. Patient usually blond or red haired and has light colored eyes what condition?
Rosacea tx: Metrogel (metroniazole) gel or azelaic acid or lowe dose tetra or minocycline given over several weeks.
Dome shaped paules with central umbilication (white plug) know as?
Molluscum contagiosum, caused by poxvirus.
Spread by skin to skin direct contact. More common in kids and takes 6-12 months to clear up.
If its located in the genitals consider sexual abuse in children
First time the thrill is palpated is at grade?
What diagnostic study used for AAA?
Abdominal ultrasound and CT
Risk factors for A-fib?
HTN, CAD, caffeine, nicotine, hyperthyroidism, alcohol, heart failure, LVH, pulmonary embolism, COPD, sleep apnea etc.
tx with beta blocker first then CCB and dig.
What is pulsus paradoxus?
Decrease of the systolic pressure by 10 points in inspiration.
Isolated systolic HTN tx in elderly?
Preferred medication low dose thiazide diuretics or CCB.
First line tx for heart failure?
ACE or ARBs
Middle aged woman complains of chronic and recurrent episodes of color changes on her fingertips in a symmetric pattern (either hands or both feet). The color ranges from white and blue to red. What condition being described here?
tx: CCB such as nifedipine or amlodipine (Norvasc).
Avoid touching cold objects, cold weather, avoid stimulants such as caffeine, smoking cessation etc.
Avoid vasoconstricting drugs e.g. Imitrex, pseudoephedrine/decongestants, amphetamines, avoid beta blocker.
First line tx for HTN?
Lifestyle and dietary changes
S/S of bacterial endocarditis
Splinter hemorrhages on nails, Janeway lesion (red macules palms/soles not painful), Osler's nodes (painful violaceous nodes found mostly on pads of the fingers and toes).
Contraindication for beta blockers?
Asthma, COPD, chronic bronchitis, Emphysema, bradycardia and AV block.
Adverse effects of beta blockers?
Bronchospasm, bradycardia, depression, fatigue, ED, HF, hypoglycemia, sexual dysfunction
Aspirin irreversibly suppresses platelet function for?
Feverfew used for?
Anxiety and insomnia
You have a patient with HTN and BPH what medication you can prescribe?
Alpha blocker example; Hytrin
What type of testing is recommended before starting patient on hydroxychloroquine (plaqenil)?
Eye exam because it can adversely affect the retina (loss of central vision, loss of color vision etc). long term therapy increase the risk of retinal toxicity.
Herniated disc and sciatica __________with standing and _____ with sitting
better with standing
worse with sitting
Lumbar stenosis is aggravated by ___________, relieved by __________.
aggravated by long periods of standing and walking
relieved by sitting and rest
Female with light scant bleeding in 6-7 weeks, lower abd pain, intermittent cramping, pain radiating to right shoulder and pain is worsen with supine position?
Ectopic Pregnancy. Previous ectopic preg, tubal ligation, PID, anything that cause scaring.
Gold standard test for TB?
Sputum for C&S
5MM> is positive for TB if
immunocompromised or person in close contact
10mm> is positive for TB if
immigrants and migrant workers
> 15mm is positive for TB if
Patient with sensorineural hearing loss, what would you see in Weber?
Localizes to better ear
Patient with sensorineural hearing loss, what would you see in Rinne?
Air conduction is greater than bone conduction
Patient with conductive hearing loss, what would you see in Weber?
Localizes to affected ear
Patient with conductive hearing loss, what would you see in Rinne?
bone conduction is greater than air conduction
Normal Weber Test
hear it equally from both sides; no lateralization
Normal Rinne test
air conduction greater than bone conduction
What is a Cullen's sign?
A bluish discoloration or bruising that is located on the umbilical area.
During a breast exam of a 30-year-old nulliparous woman, the nurse practitioner palpates several rubbery mobile areas of breast tissue. They are slightly tender to palpation. Both breasts have symmetrical findings. There are no skin changes or any nipple discharge. The patient is expecting her menstrual period in 5 days. Which of the following would you recommend?
Advise the patient to return 1 week after her period so her breasts can be rechecked
A preschool girl who is homeschooled is brought by her mother to the walk-in clinic because of acute onset of fever, runny nose, cough, sore throat, and red eyes with a morbilliform rash. The mother reports that her daughter has never been immunized. The family recently returned from a vacation. Which of the following conditions is the most likely?
Rubeola (Measles) caused by rubeola virus. It is very contagious and is transmitted via droplets like the common cold.
You will see Koplik's spots (tiny white spots in buccal mcusoa) during the prodromal periods. Morbilliform rash.
Tx is symptomatic and mostly recovery seen in 2-3 weeks.
Mother brings in 12 month old infant reports to the NP that her child had a high fever for several days which spontaneously resolved, after the fever resolved the child developed a maculopapular rash what are you thinking is going on with patient?
Roseola infantum (exanthema subitum) caused by human herpesvirus.
Common age 6-48 months.
You are checking a 75-year-old woman's breast during an annual gynecological exam. The left nipple and areola are scaly and reddened. The patient denies pain or pruritus. She has noticed this scaliness on her left nipple for the past 8 months. Her dermatologist gave her a potent topical steroid, which she used twice a day for 1 month. The patient never went back for the follow-up. She still has the rash and wants an evaluation. What would you do?
Order a mammogram and refer to breast surgeon. Paget's disease of the breast is rare type of cancer involving the skin of the nipple and usually the areola.
Positive psoas and obturator sign is highly suggestive of what condition?
Where are the sentinel nodes (virchow's nodes) are found?
Left superaclavicular area. They are the first lymph nodes that a cancer lesion will drain into.
Therefore, when cancer is diagnosed, these nodes are biopsied to see whether the cancer has spread into the lymph system.
A 55-year-old woman brings her mother, who is 82 years of age, to the emergency department of a local hospital. She reports she found her mother on the floor when she checked on her that morning. Her mother was awake and oriented, but needed help getting up. Her mother states that she thinks she passed out. She is being evaluated by a physician who orders an EKG and x-rays of both hips. Regarding laboratory testing, which of the following tests is important to perform initially?
Blood glucose. Checking the blood glucose is indicated for patients with syncopal and near-syncopal episodes.
The nurse practitioner should also perform a thorough history of the incident.
Possible causes of syncope are cardiac arrhythmia, vasovagal, hypoglycemia, orthostatic hypotension, seizure, accidental fall, and others
A 12-year-old girl is complaining of a 2-week history of facial pressure that worsens when she bends over. She complains of tooth pain in her upper molars on the right side of her face. On physical exam, her lung and heart sounds are normal. Which of the following is the most likely diagnosis?
A 22-year-old sexually active woman is complaining of amenorrhea and new-onset bloody vaginal spotting. On examination, her left adnexa is tender and cervical motion tenderness is positive. Which test should the nurse practitioner order initially?
The patient's history of amenorrhea and new onset of bloody vaginal spotting combined with positive physical findings of left adnexal tenderness and cervical motion tenderness are highly suggestive of an ectopic pregnancy rather than pelvic inflammatory disease (PID).
Refer this patient to the emergency department if ectopic pregnancy is suspected. The presence of amenorrhea should be treated as a pregnancy until proven otherwise.
A nurse practitioner is doing a funduscopic exam on a 35-year-old woman during a routine physical exam. He notices that she has sharp disc margins and a yellowish-orange color in the macular area. The ratio of veins to arteries is 3:2. What is the next most appropriate action?
Advise patient that she had normal exam. Optic disk of a normal examination has sharp margins, a yellowish orange to a creamy pink color, and round or oval shape.
How do you evaluate cremasteric reflex?
Stroking the inner thigh of a male patient and watching the testicle on the ipsilateral side rise up towards the body.
The nurse practitioner notices a gray ring on the edge of both irises of an 35 years old? What is the significance of this finding?
Check patient's lipid levels. Arcus senilis is caused by lipid deposits deep in the edge of the cornea and is quite commonly present in elderly. However, it can also appear early in life as a results of hypercholesterolemia.
What is used to screen for color blindness in the 7 year old boy?
Carpal tunnel syndrome is due to inflammation of the?
Bouchard's nodes are associated with which of the conditions?
What is the cheap and easy test performed for sciatic nerve/herniated disk pain in primary care office?
Straight leg raise
Complications of untreated gout include?
Impaired joint mobility and renal damage. Left untreated, gout can develop into a painful and disabling chronic disorder. Persistent gout can destroy cartilage and bone, causing irreversible joint deformities and loss of motion. High uric levels can deposit in the kidney and also lead to kidney stones.
40 year old nurse complains of new onset of back pain secondary to her job on the medical surgical floor. She reports lifting some obese patients while working the previous night shift. She reports to the worker's compensation clinic where she was referred. She describes the pain as starting in her right buttocks area and radiating down the back of her thigh. It becomes worse when she sits down for long periods of time. What you think is going on with patient?
Sciatica (pain worse with sitting, improves with walking) (herniated disc and spinal stenosis pain worse with walking better with sitting).
Lachman maneuver is used to detect?
Instability of the knee.
Infection of the skin mucous membranes with HPV is associated with an increased risk of which type of cancer?
Orophargneal, larynx, anus, penis and cervix cancer.
Fifth disease also knows as?
Erythema infectiosum. Lab test? Parvovirus B19
A 36-year-old woman complains of fatigue and headaches accompanied by widespread muscle and joint pain that started 6 months ago. She reports insomnia and feeling tired even with adequate sleep. She was diagnosed with major depression 1 year ago and is currently on escitalopram (Lexapro) 20 mg PO daily. She is also taking B-complex vitamins and melatonin at bedtime for sleep. During the physical exam, the nurse practitioner notes bilateral areas of tender points on the neck, jaw, shoulders, chest, upper back, and greater trochanter. The symptoms and physical exam findings are highly suggestive of which condition?
You see 18 years old female student who has been given a booster dose of MMR at the college clinic what would advise her?
She should not get pregnant within the next 4 weeks.
What pathogenic bacteria are commonly found in the lungs of older children and adults with cystic fibrosis?
Anti HCV test of 60 years old female is positive which test is appropriate for f/u?
HCV RNA used for current or past infection.
What is a gold standard test for visualizing a torn meniscus or joint abnormalities?
What kind of food do you recommend for postmenopausal women with osteopenia?
Good source of calcium including low fat dairy products such as yogurt, dark leafy vegetables, canned salmon or sardines with bones, soy products, and calcium fortified cereals.
A middle-aged woman has been experiencing low-back pain that recently started to radiate to both buttocks and down her legs. She complains of leg weakness and problems with walking. Along with these symptoms she reports new onset of urinary incontinence, in which she leaks a small amount of urine at random. She also reports numbness on her perineal area, which is new. She denies trauma but reports that she recently moved to a new apartment and has been lifting and moving furniture. Which of the following is best described?
Caude equina syndrome
Phalen test is used to evaluate?
Carpal tunnel syndrome. T he test is performed by pushing the back of the hands together for 1 minute. This compresses the median nerve within the carpal tunnel. Characteristic symptoms (burning; tingling; numbness over the thumb, index, middle, and ring fingers) convey a positive test result.
Osteopenia is defined as T-score?
-1.0 to -2.5
Osteoporosis is defined as T-score?
-2.5 and less.
A sexually active 22-year-old man is asking to be screened for hepatitis B because his new girlfriend has recently been diagnosed with hepatitis B infection. His lab results are the following: anti-HBV is negative, HBsAg is positive, and HBeAg is negative. What vaccines are recommended for this patient?
The patient needs hep B vaccine and hep B immunoglobulin.
45 year old man walk in private clinic and reports of stepping on a nail that morning. His last tetanus vaccine was 7 years ago. What would you give him?
TDAP because puncture wounds are at high risk for tetanus because of clostridium tetani bacteria are anaerobes.
What would you see in patient with mononucleosis?
It is caused due to EBV symptoms include lymphadenopathy, fever, heatosplenomegaly, malaise, and abdominal pain.
Fitz-hugh-curtis syndrome is associated with?
Chlamydia trachomatis (perihepatitis) is a complication of PID. It is more common with chlamydial pID but it can also occur with Gonorrheal PID infection as well.
if caused by inflammation of the liver capsule which leads to scarring. Treated with antibiotics.
HPV infection in women has been associated with the development of which type of cancer?
Which type of HPV strain is responsible for cervical cancer?
HPV subtypes 16 and 18.
What is used to diagnose gonorrheal pharyngitis or proctitis?
21 year old college student has recently been informed that he has a HPV infection on the shaft of his penis. What would you use to visualize subclinical HPV lesions on the penile skin?
Apply acetic acid to the penile shaft and look for acetowhite changes.
A male 16-year-old with a recent history of a cat bite is brought to the walk-in clinic by his mother. The bite occurred about 2 hours before the visit. The nurse practitioner evaluates the wound and notes two small puncture wounds. There is no redness or purulent discharge. The mother reports that the teenager received a tetanus booster when he was 12 years old. How would you treat this patient?
Clean the wound with soap and water and prescribe Augmentin 500 mg bid x 10 days
An 18-year-old female patient has a positive throat C&S for Streptococcus pyogenes (group A beta streptococci). The patient reports a history of an allergic reaction to penicillin with "swollen lips" accompanied by itchy hives. Which of the following is the most appropriate treatment?
A) clarithromycin (biaxin) 250 mg bid x 10 days
B) gargle with salt and water
C) Keflex 250 mg qid x 10 days
D) doxycycline 100 mg po bid x 10 days.
clarithromycin (biaxin) 250 mg bid x 10 days
(r/o option c as patient allergic to PCN and option D as doxy not effective for gram + infection?
A 25-year-old healthy male who is a nonsmoker is diagnosed with atypical pneumonia. The patient reports a history of nausea, upset stomach, and vomiting with erythromycin. The vital signs are temperature of 99.8Â°F, pulse of 80/min, and respiratory rate of 16 breaths/min. how would you treat this patient?
Azithrmycin PO x 5 days.
Patient who is 24 years old Pap results shows LSIL what would you do next?
Repeat pap in 12 months
Patient who is 26 years old Pap results shows LSIL what would you do next?
f/u with colposcopy with cervical biopsy.
52 y. o female patient presents with palpitation, tachycardia, tremors, losing weight, heat intolerance what are you thinking going on with patient?
Hyperthyroid, TSH- low, T4 high and T3 normal or high.
Treatment- PTU, Methimazole (Tapazole), Radioactive iodine.
When do you check thyroid function panel after starting patient on levothyroxin?
slightly elevated TSH> 5.0, T4, T3 normal DO NOT TREAT, RECHECK 6 MONTHS
PTH is responsible for calcium loss or gain from bone, kidneys, and GI tract
If your patient on two oral antidiabetic drugs and his/her A1C is 10 what would you do?
basal insulin (levemier)
Cushing syndrome symptoms
central obesity, moon face, buffalo hump, purple striae , hairy, HTN, elevated plasma CORTISOl in AM, increase blood glucose, increase Na+, decrease K+.
low level of CORTISOl (think low sodium, low blood glucose) increase K+, thin women with bronze color, hypotension. (dx plasma cortisol <5 mcg/dl).
check blood sugar for 2-4 weeks. Similar to A1C test but not used for screening.
too much insulin in the blood at night causes a rebound increasing blood sugar in the morning.
Tx- lower insulin at night time
early morning early increase in blood sugar between 2-8 am.
Tx- increase night time insulin
diagnosed by amylase and lipase, amylase begins increasing in 2-12 hours after onset of symptoms. Lipase begins to increase in 4-8 hours after onset of symptoms. Lipase more specific and sensitive to alcoholic pancreatitis
Peripheral artery disease (PAD)
intermittent claudication (leg pain when walking, relieved with rest), shiny, hyperpigmented, hairless skin on BLE, decreased or absent pedal pulses, increased cap refill, bruits over partially blocked arteries. High risk in patient with HTN, hx of PAD, smoking, DM, HLD, tx- smoking cessation, daily exercise, ankle and brachial bp before and after exercise. ASA or plavix to prevent blood clots. Long term or last resort tx- precutaneous angioplasty or surgery for severe cases. Normal ABI 0.91-1.3
Which antihypertensive medication contraindicated in GERD
CCB and BB
Medication that can cause HF?
NSAIDs, Glitazones, CCB/BB and cancer medications
How do you treat ISH in elderly?
CCB (Amlodipine, nifedipine etc) and ISH systolic >140 with diastolic <90.
Patient presents with fever, chills, malaise associated with subungal hemorrhages (Splinter hemorrhages on nailbed) and tender, violet-colored nodules on fingers/toes (Osler's nodes), palms/soles and heart murmur what you think is going on with patient?
Bacterial Endocarditis. Tx with IV antibiotics, BC, CBC, ESR, refer to ED or cardiologist
S/S of CHF?
Dyspnea, orthopenea, fatigue, cough, edema, bibasilar crackles, S3 heart sounds, resting tachycardia, diaphoresis, tachypnea
Elderly women on digoxin, crt went from 0.8 to 1.2 what would you do?
Normal crt 0.6-1.1. lower dig to prevent toxicity
Contraindications for taking ACE inhibitors
Moderate to sever kidney disease, bilateral renal artery stenosis, previous angioedema associated with ACE
Side effects of thiazide diuretics?
Hyperglycemia, hyperuricemia, hypertriglyceridemia, hyperlipidemia, low K+, low Mg
Goal INR for synthetic/prosthetic valves?
Anterior wall MI or anterior STEMI?
EKG shows ST elevation in lead V2 and V4 and q-wave. Wide QRS complex resembles a tombstone
High pitched murmur radiating to left axilla
MR (MR. ASS and MS. ARD)
Medium pitch heart at Aorta area radiating to neck?
Midsystolic click heart at mitral area?
MVP (common in middle age female c/o palpitation, fatigue, lightheadedness. Tx with beta blocker, avoiding alcohol, cigarettes, and caffeine intake)
Coactions of aorta?
BP elevated in upper and low in lowers
Patient presents with lower extremities edema, disocoloration, ulceration, warm to touch what are you thinking?
Chronic Venious Insuffiency or PAD
First line tx for CHF?
ACE or ARB
Cholesterol <200, HDL >40, LDS<100, Trig <150 first line treatment
Life style modification then fenofibrate (Tricor) or niacin
Common cause of LVH in USA?
Patient complains of the abrupt onset of palpitations, rapid pulse, lightheadedness, shortness of breath, and anxiety. Rapid heart rate can range from 150 to 250 beats/min?
Proxysmal superventricular tachycardia (SVT). May be seen in wolff Parkinson white syndrome which is more common in children caused due to dig toxicity, alcohol, hyperthyroidism, caffeine intake, illegal drug use etc
A 65-year-old man has been on atorvastatin (Lipitor) 60 mg daily for the past 3 months. Two weeks ago he started taking a high-dose B-complex vitamin. He complains of feeling very fatigued lately and denies lack of sleep. He has noticed that he has a loss of appetite and his urine has been a darker color for the past 2 weeks. He denies dysuria, frequency, and nocturia. The nurse practitioner notices that the patient's sclera has a slight yellow tinge. You would:
You would: discontinue Lipitor and order LFTs
You have a patiient with HTN and osteoporosis, why would you put them on Thiazides?
Thiazides (slows down calcium loss from bone and stimulating osteoclasts
I am a healthy 63-year-old patient, what is my goal BP according to JNC 8?
<150/90 for 60yrs+
Recall that less than 60yrs is <140/90 in addition to those with DM and CKD
A low HDL and high trig level always means what:
Side effect of spironolactone?
Gynecomastia hyperkalemia, and impotence
The S1 is the closure of which valves?
AV valves (mitral & Triscuspid)
Closure of semilunar valves
S2 heart sound
Indicate allergies, cancer, or parasitic infection
Hep A is transmitted:
Transmitted thru contaminated food and water
Hep B is transmitted:
Transmitted thru blood, sexual activity and mother child transfer at birth
Hep C is transmitted:
Transmitted thru mother and child at birth, tattoos and contaminated needles, hemodialysis, sexual contact
What is TORCH?
Toxoplama, other infections, rubella, cytomegalovirus, herpes
Dx study for thalassemia?
How do you dx IDA?
Serum ferritin, TIBC
HBsAG- tells us:
acute or chronic infection ( if positive chronic hep b)
Anti-HBc? When this is positive it means you have:
HBV infection or had it at some time in the past. (hep b core antibody. No antibody never had hep B)
Anti-HBs? Tells us if:
if immune due to previous infection or vaccination (Hep B surface antibody + means immunity).
A newborn's mother is discovered to be HBsAg (hepatitis B surface antigen) positive. Which of the following would you recommend for this infant?
Give BOTH the Hep B vaccine and immunoglobulin
A 68-year-old woman is suspected of having Alzheimer's disease. Which of the following is the best initial method for assessing the condition?
Most likely cause of delirium?
First line treatment for PTSD?
Zoloft or paxil
SSRI side effects?
ED, decrease libido, anorexia, insomnia, suicidal thinking
Examples of SNRIs?
MAOIs avoid food high in?
Tyramine content such as fermented foods beer, wine, cheese, fava, beans etc.
Bupropion (Zyban) is used for?
Smoking cessation, patient can smoke while on this medication.
What is munchausen syndrome?
Falsifies symptoms of factitious disorders (abd pain, chest pain, seizures etc
Atypical pneumonia causative organisms?
M. Pneumoniae, C. Pneumoniae, L. Pneumoniae . tx- Macrolides or Doxycycline 100 mg bid x 7-10 days
Top two bacteria in CAP are & treatment?
S. Pneumoniae and H. influenzae.
Tx in patient with no comorbidity- Macrolides. If patient had antibiotic therapy in last 3 months use Doxy or levaquin.
With comorbidity such as CHF, kindey disease, liver disease etc use to treat respiratory disorders:
respiratory fluoroquinolone such as moxifloxacin, levofloxacin or gemifloxacin.
If allergic to Res quinolones use agumentin or cefdinir (Omnicef) plus macrolides
Tx for Pertussis (whooping cough)
Induration of 5 mm or greater seen in which population?
HIV, recent contact with infectious TB personal, immunocommpromised
Induration of 10 mm or greater seen in which population?
recent immigrants, health care workers, homeless, iv drug users, employee or residents from high risk congregate settings such as jail, nursing home.
What is FEV1 ratio for mod persistent asthma?
60-80% tx. Albuterol as needed plus low dose ICS plus LABA or medium dose ICS. Example fluticasone with salmeterol (Advair) or budesonide with formoterol (Symbicort) or medium dose ICS alone budesonide (Pulmicort), flovent .
Knee instability test
Medial pain in knee
Valgus stress test (MCL), gum stuck between the knees
Lateral knee pain
Varus stress test (LCL), bowlegs
Wrist pain on palpation of the snuffbox, pain on axial loading of the thumb and hx of falling forward with outstretched hand (hyperextension of the wrist)?
Navicular fx. Initial x-ray may be normal but a repeat x-ray in 2 weeks will show the scaphoid fx. High risk of avascular necrosis. Splint wrist (thumb spica splint) and refer to a hand surgon.
Patient c/o acute onset of saddle anesthesia, bladder incontinence and fecal incontinence suggest?
Cauda equine syndrome
Finkelstein' test done for?
De Quervain's tenosynovitis is caued by an inflammation of the tendon located at the base of the thumb.
Medial tibial stress syndrome or fx?
Common in runners and people with flat feet. If sever can progress into a stress fx. Female are at higher risk for stress fx those with "female athlete triad" (amenorrhea, eating disorder and osteoporosis). Also known as "shin splints".
Tx includes RICE, compression bandage for swelling, lower impact exercise such as swimming, stationary bike.
Patient c/o acute or recurrent pain on the bottom of the feet that aggravated by walking with foot pain that worsen during the first few steps in the morning and worsen with prolonged walking?
Plantar fasciitis. Tx includes NSAIDs, topical NSAIDs, apply ice pack to affected foot, weight loss, stretching and massaging of the foot, consider x-ray to r/o fx, heel spurs.
chronic, progressive arthritis with stiffening of joints, primarily of the spine
Bamboo spine is pathognomic for alkylosing spondylitis.
SLE (systemic Lupus Erythematosus
More common in African American, Hispanic women. More typical in women between 20-35years. Rash is maculopapular butterfly shaped rash on the middle of the face (malar rash). Tx topical or oral steroids, plaquenil, methotrexate, biologics. Avoid sun, cover skin with high SPF sunblock, and wear sun protective clothing.
What type of exercise recommended for patient with DJD or OA?
Weight bearing exercise including swimming, walking or biking. Herberden's node (distal) and Bouchard's node (Proximal). Recommend stop smoking, lose weight, Tylenol for pain
Exercise for osteoporosis
weight bearing exercise including walking, jogging, biking, aerobic dance. Swimming and isometric exercise are not considered weight bearing.
Middle aged woman complains of gradual onset of symptoms over months with daily fatigue, low grade fever, generalized body aches, myalgia, c/o joint pain worsen in the morning lasting 60 min, early morning stiffness, pain warm, tender and swollen fingers in the DIP/PIP joints?
RA, elevated sedimentation rate, CBC with anemia. Tx NSAIDs, steroids, steroids shots, DMARDs (methotrexate, cyclosporine etc), and hydroxychloroquine (antimalarial drug). RA non weight bearing. Swimming and isometric exercise.
Middle aged man presents with painful, hot, red and swollen metatrasophalangeal joint of great toe (podagra)?
Gout, tx NSAIDs, cochicine 1.2 mg. complication joint destruction and kidney failure.
Golfer's elbow (Medial epicondylitis):
gradual onset of aching pain on the medial area of the elbow. Higher in baseball players, bowlers, and golfers.
Tennis elbow (Lateral epicondylitis):
gradual onset of pain on the outside of the elbow that sometimes radiates to the forearms. Pain worse with twisting or grasping movements (opening jars, shaking hands etc).
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